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General NPI Number Information
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NPI Number | 1639434764
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Entity Type | Individual
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Provider Name | GREGORIS KOMODIKIS MB BS
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Gender | Male
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Dates
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Enumeration Date | 07/04/2012
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Last Update Date | 09/11/2015
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Provider Practice Location Address
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Address Line | 909 WALNUT ST 2ND FLOOR
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City | PHILADELPHIA
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State | PA
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Zip | 19107-5211
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Country | US
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Telephone | 215-955-7000
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Fax | 215-503-7007
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Provider Business Mailing Address
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Address Line | 1 RICHMOND ST #3069
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City | NEW BRUNSWICK
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State | NJ
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Zip | 08901-4100
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | MD455231
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License Number State | PA
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